Aojte Psychoses FOLLOWING Gynecological Operations BY EDWARD J. ILL, M. D., Surgeon to Woman’s Hospital and Gynecologist to St. Barnabas Hospital, Newark, N. .). KKPRINTED FROM THIS PITTSBURGH MEDICAL REVIEW, January, 1888. Acute cological Operations Edward J. Ill, M. D., Newark, N. J. Surgeon to Woman’s Hospital and Gynecologist to St. Barnabas Hospital op Newark, N. J. Within the last few years a great deal has been said about curing neuroses and psy- choses by operations upon the genital organs of women. surgeons will testify to the truth of this assertion. No one, how- ever, can boast of a very extensive experience in this direction, and the failures have been many. The opposite, namely, the produc- tion of psychoses by such operations, may be still more seldom ; and never having come across such cases in medical literature until* within the last week, I think that my experi- ence is quite unique. The following histories will, I trust, be of interest. Case 1. Mrs. M. B., of Hope, N. J., was admitted into my service in the Woman’s Hospital of this city on November 3, 1884, with the following history: She was the 2 wife of a Methodist minister, was 61 years old, of fair general health and well nour- ished. She had been married forty years, had had five children, no diffi< ult labors and no miscarriages. All her children are living and none troubled with neurotic disease. Her last child was born 21 years ago. Her father died of apoplexy and mother of old age. She never suffered from her menstrual periods, and the menopause occurred at the age of 47 years. The duration of her present illness was one year, and was attributed to a fall, from which accident she lost some blood per vaginam. At this time she also noticed an increasing enlargement of the abdomen. Locomotion produced sharp pain in the left inguinal region. She also complained of a bearing-down sensation in the lower part of the abdomen. Physical examination revealed .normal heart, lungs and kidneys. The ab- domen appeared somewhat flattened and cov- ered with a thick la37er of fat. The umbilicus presented as an irreducible hernia. There was tympanites over the epigastrium reaching on both sides to the axillary line, and dull- ness on percussion over the rest of the ab- domen. Measurements were as follows: 3 Around the abdomen, over the umbilicus, 43 inches ; from os pubis to xyphoid cartilage, 16 inches. There was distinct fluctuation all over the abdomen. Upon deep palpation a hard, nodular, very movable and apparently solid tumor was found, reaching from the pelvis to three inches above the umbilicus. Per vaginam, the cervix and corpus uteri were found to the right of the median line, the tumor high up to the left of the uterus. Movements of the tumor were only slightly imparted to the cervix. Diagnosis: Solid tumor (Sarcoma) of left ovary, with ascites. After some preparatory treatment as regards the bowels, diet, baths and a five days’ stay in the hospital, during which time nothing was discovered concerning any mental de- rangement of the patient, the tumor and ascitic fluid, on November 8th, were removed. The twisted pedicle was ligated, seared with Paquelin’s cautery and dropped. The tumor proved to be one of the left ovary, and is called by the pathologist a fibro-sarcoma. It weighed fourteen pounds. A Thomas drain- age tube was left in the peritoneal cavity. Time of the operation, including anaesthesia by aether, was one and one-lialf hours. Tf e 4 anaesthetic was given by an expert, and 0.01 gm. of morphia, hypodermically, preceded the anaesthetic by half an hour. The umbili- cal hernia was found to contain adherent omentum. This was cut off and the hernial sac excised. The wound, which was eight inches long, was dressed in the manner customary in this institution, namely, with iodoform and borated cotton. Everything was done with careful antiseptic precaution, carbolic acid being the antiseptic used. When the patient came out of idle anaesthesia, which was in less than an hour, she complained of shortness of breath. She perspired freely, had a good pulse of 110, temp. 100°, and re- spiration 20. November, 9th, at 9 p. m. , the patient was reported to have slept all the afternoon. The face was still flushed, the skin dr}r and hot and tongue moist. Pulse was 120, temp. 103.4°, respiration 32. No- vember 10th, at 9 a. M., pulse 120, respira- tion 28, temperature 103.2° ; skin moist and face still flushed. There was removed 300 gm. of serum from the drainage tube, to which there was no bad odor. All the iodo- form was carefully removed from the skin and replaced by salicylic acid. The perito- neal cavity was irrigated with a solution of mercuric chloride 1 to 5000. At 9 P. M., temp. 102.6°, 60 gm. of slightly tinged serum was removed. The irrigation was repeated as above. November 11th, at 9 A. M., temp, was 101.8°, and irrigation of the cavity was repeated. The disturbed condition of the patient’s mind increased. At 9 P. M. temp, was 100° ; pulse, 110. She had passed flatus freely during the day, and there was no ten- derness over the abdomen. November 12th, at 9 A. M., temp, was 102°, and the irrigation was repeated. In the evening her tempera- ture wasagain 100°. November 13th, patient has become wildly delirious, but at times re- lapses into a stupid condition. On Novem- ber 15th the drainage tube, and on November 17th the stitches were removed. The union of the wound was found to be perfect except a slight discharge from the site of the drainage tube. Her temperature remained at 100°. November 18th she relapsed into a melan- cholic stupor, and recognized not even her husband or her daughter. November 25th, no fever since November 17th; she still suffered from melancholia, and there seemed to be a slight drooping of the left eye-lid and 5 left corner of the mouth. November 27th, she was sent early in the afternoon to the house of her daughter, who lives in the city. When there she immediately went to sleep. November 28th, I saw her at 10 a. m., and was told that she was still asleep and had slept all night. She was easily aroused. She in- quired whether the operation was all over. From further conversation it was elicited that the period from the time she was put under {ether. November 8th, until my call, on November 28th, was a blank in her life. She was well about six months ago, when I last heard of her. Case 2. Mrs. J. W., of this city, was ad- mitted September 7, 1885. German—aged 57 years—widow—had two children, the last 29 years ago. Menstruation first appeared at the age of 14 years, was regular and pain- less. Her menopause occurred eight years ago. There is no history of neurotic disease in the family. Her general health is very poor. She is a hump-backed little woman, with oedema of the feet, legs, thighs and skin of the abdomen. She is of unpleasant dispo- sition, and only permits an operation because she hopes to die from it and thereby end her 6 sufferings. The duration of her present ill- ness is three years. At that time she noticed a lump in the left side of her abdomen, which grew rapidly, and was tapped twenty-seven times during two years, removing over 300 pints of thick grayish white fluid. Of late her physician tapped her every two or three weeks. Physical examination revealed normal heart, lungs and kidneys. The abdomen was distended by an uneven tumor, fluctu- ating at certain places and hard and unyield- ing at others. The whole tumor seemed to be immovable, and there was tympanites in both flanks and epigastrium. Circumference of the abdomen over the umbilicus was 40 inches ; ensiform cartilage to os pubis, 15 inches ; vaginal portion of the uterus low in the pelvis and the corpus apparently poste- rior to the tumor. Diagnosis: Multilocular ovarian tumor. Operation September 12, 1885. Preparatory treatment, antiseptics, aether, etc., as in the foregoing case. Incision, 9 inches. Tumor firmly adherent to intestines, abdominal walls, omentum, mesentery and lower border of the liver. There were no pelvic adhesions, and this por- 7 tion of the tumor was reached first. The pedicle, three inches wide, was ligated and dropped. The tumor was then separated from its adhesions and removed. Some thirty silk ligatures were applied to bleeding points in the abdomen. The operation lasted two hours. Toward the latter part of the operation the pulse got feeble, and brandy was given hypodermically. A drainage tube was inserted and iodoform powdered over the wound. Patient reacted very well, al- though her pulse remained at 120-130 for some days. The temperature never rose above 100°, and that temperature was re- corded on the third day. The drainage tube was removed on the sixth day. On Septem- ber 20th the stitches were removed and union found complete. On this day the patient began to wander—talked a great deal and in- coherently. The iodoform was carefully re- moved from the skin and salicylic acid placed there. September 21st,patient became more and more irrational; did not sleep any during the night; wanted to sit up and go out, and was continually troubled about being abused by her son-in-law. There was no fever and her pulse was normal. On September 24th 8 her condition became such that it was im- possible to keep her in the institution, and, at the request of her daughter, she was sent home. After two weeks’ time she gradually became herself again. At the present she is as healthy as she ever was, looking- after a large household. Case 3. Mrs. S. D., of this city, Ameri- can, aged 24 years, of good history, married four years, has had two children, one miscarriage, at two months, occurring four months ago; has been complaining since the birth of her last child. Patient is pale, exceedingly nervous, and labors under the fear that she will never get well. First menstruation occurred at the age of 14 years ; was regular. She suffered some pains on the first day of the flow-. At present menstruates regularly for four days, with a sensation of heaviness in the pelvis. She complains of frequent micturition at night, every hour, as well as by day time. During defecation has a bearing-dowm pain in the back. Urine is cloudy, opaque, and contains some pus. The patient’s uterus is retro- verted, not replacable, slightly enlarged. 9 The urethra is exquisitely sensitive. A linear sore about | of an inch from the meatus is brought to view by a cylindrical speculum. After some treatment for the retroversion and for the urethra without any benefit, Emmet’s buttonhole operation was performed on January 25, 1886. A marked change in the patient’s mental condition was recorded on the next day. She sat in her bed, continually moaning, 11 Oh, dear ! oh, dear !” and would not answer any questions, but looked at one most piti- fully. Her condition was one of deep mel- ancholia. Any treatment to the sore urethra was accomplished only with the greatest difficulty. The ulcer of the urethra, how- ever, got well, but her mental condition re- mained the same. In this lamentable condi- tion she was sent home on February 13th. She passed her water as frequently as ever, but no questioning elicits anything about pains during the act. After some weeks she began to answer questions, and made the as- sertion that she would never be able to care for her children again. At this time she also complained of a return of painful micturi- tion. Nothing abnormal was detected in the 10 urethra, but there still continued to be pus in the urine. About live weeks after her dis- missal from the hospital her mental condi- tion was again normal. It may be of some interest to know of the after lnstorjr of this case. In May of the same year an opening was made into the bladder, since the patient’s condition was almost intolerable. The operation was done at the patient’s home. The result was most satisfactory, since she got entirely well from her pain, became quite stout, and manifested no nervous symptoms at all. She became pregnant, underwent replacement of the uterus, at the fourth month of pregnancy,and gave birth to a child in June, 1887. The fistula was still present at the time her uterus was anteverted. Since writing the above the fistula was operated on. and patient is well. It will be necessary to describe, and I shall endeavor to eliminate, any condition in the hospital that might cause such trouble- some consequences as those described; for it is of the utmost importance to anatyze these cases carefully. The hospital is one used only for gynecological cases, with sep- arate ovariotomy rooms, is well lighted and 11 12 ventilated and kept scrupulously clean. It is under the care of Roman Catholic sisters, and the sister in charge is a quiet, most ex- perienced and faithful nurse. The first patient, as already remarked, was a Methodist, and had great objections to going into a hospital conducted by Roman Catholic sisters. This was, however, soon overcome, after the first few days of her stay. The other two patients were Roman Catholics. The fact of the religious charac- ter of the institution, of the patients or the nurses had, I think, nothing to do with the condition of the patients, especially so since the turn of mind in no patient was that of religious insanity. There was no history of insanity in either of the patients or in their families, nor do I see any reason to believe that there was an injury to peripheral nerves to which the mental condition might be attributed. The quantity of iodoform was small and covered cutaneous surface only. This was carefully removed as soon as an}’ manifesta- tions of irrationality presented themselves.* *01shausen ascribes a case of acute mania to iodoform, four weeks after its discontinuance. “ Centralblatt fuer Gynrnko- logie, 1887, p. 467.” The use of morphia and aether, combined, can hardly be blamed for this vice, since this combination is frequently used, and I have still to hear of any detrimental effect. All the sponges were dipped and pressed dry from a 22 per cent solution of carbolic acid before being returned to the surgeon. The urine never showed any signs of carbolic acid intoxication. The nervous disposition of the three women was quite different. While the first one never manifested an}r sensation of fear from the operation, the second one wished the operation with the hope of dying, for she had no confidence about getting well. The third case was one where the patient al- ready manifested of mental aber- ration from the beginning of observation ; for example, the fear that she would never get well. In Case 1 the condition was thought for a time to be a delirium due to septic infection, but when all fever ceased she had a right to a better mental condition. Was it homesickness ? Hardly that, since one of her own people was with her during the latter part of her sickness. The nearest I can get at any cause is that of shock, pro- 13 duced by the operation,and kept up, to some extent, by a septic (?) fever. It is well known how often acute fevers are recorded as causes of acute insanity. This would, however, not account for the peculiar sudden restoration to health after the return to her daughter’s home and the long sleep. Whether she would have been restored to her senses if she had remained in the hospital one day longer no one can say. In the second case, the long drain on the system by the frequent tapping (removal of 300 pints of fluid from the tumor in the space of two years), similar to a long suppurating sore, producing anaemia of the brain,* seems most likely to have been the cause. In the third case, the excessively nervous condition of the patient must be taken into account, as well as the great drain upon her nervous system produced by sleepless nights, superinduced by an operation and only a partial result, although told that the opera- tion was done to get at the seat of the dis- ease more easily. Looking up the literature of the subject, I could find nothing except in an essay read before the Berlin G.ynecologi- 14 *Schuele : Handbuch der Geistes Krankheiten, p. 334. 15 cal Society in June, 1887, and the discussion following. Dr. Graubef there reports a case of perin- eorraphy by Dr. Paul Huge, where hypo- chondriasis followed. Dr. Huge himself, however, suspects that the woman was not in perfect mental health before the ope- ration. This case is of especial forensic interest since the woman’s husband threat- ened suit. Duerelius reports a similar case after am- putation of the cervix. Czempin relates, at the same meeting, five cases of acute insanity which occurred in A. Martin’s hospital. Two were cases of excision of the rectum for carcinoma, one an excision of hemorrhoids, one an operation for prolapse of the uterus and vagina, and a last one an ovarian tumor. In the last case mentioned the patient succumbed to the mania on the tenth day. Iodoform poison- ing must be excluded, since none of the drug was used. In the last case septic fever was also excluded, since there was neither a rise of temperature nor of pulse. fCentralblatt fuer Gynaekologie, p. 419, 1887. 16 These are about all the cases that I can find in the journals and books at my dis- posal. No explanation is given by the various reporters, nor what to do to prevent such an occurrence. It is bad enough when we treat patients with neuroses for some gynecological trouble and find that our treat- ment is making them worse. But when psy- choses can even be produced by a gynecolog- ical operation it is well to know when such a thing should be expected. Complete reports, with all the details of psychoses following surgical, and especially gynecological opera- tions, is that which can bring about a better understanding.